Provider Demographics
NPI:1669652673
Name:ATLANTA RETINA PC
Entity Type:Organization
Organization Name:ATLANTA RETINA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:D'HEURLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-351-0590
Mailing Address - Street 1:1720 PEACHTREE ST NW
Mailing Address - Street 2:SUITE 932
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2449
Mailing Address - Country:US
Mailing Address - Phone:404-351-0590
Mailing Address - Fax:404-351-0098
Practice Address - Street 1:1720 PEACHTREE ST NW
Practice Address - Street 2:SUITE 932
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2449
Practice Address - Country:US
Practice Address - Phone:404-351-0590
Practice Address - Fax:404-351-0098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-07
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026096207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00284501EMedicaid
GA180040998OtherRR MEDICARE
GA00284501EMedicaid
GA180040998OtherRR MEDICARE